Critical Care Medicine

Critical and Cardiac Care Patient Management
T. Scott Gallacher, MD, MS
Critical Care History and Physical Examination
Chief complaint: Reason for admission to the ICU.
History of present illness: This section should included pertinent chronological events leading up to the hospitalization. It should include events during hospitalization and eventual admission to the ICU.
Prior cardiac history: Angina (stable, unstable, changes in frequency), exacerbating factors (exertional, rest angina). History of myocardial infarction, heart failure, coronary artery bypass graft surgery, angioplasty. Previous exercise treadmill testing, ECHO, ejection fraction. Request old ECG, ECHO, impedance cardiography, stress test results, and angiographic studies.
Chest pain characteristics:
A.Pain: Quality of pain, pressure, squeezing, tightness
B.Onset of pain: Exertional, awakening from sleep,
relationship to activities of daily living (ADLs), such as
eating, walking, bathing, and grooming.
C.Severity and quality: Pressure, tightness, sharp,
pleuritic
D.Radiation: Arm, jaw, shoulder
E.Associated symptoms: Diaphoresis, dyspnea, back
pain, GI symptoms.
F.Duration: Minutes, hours, days.
G.Relieving factors: Nitroclycerine, rest.
Cardiac risk factors: Age, male, diabetes, hypercholesteremia, low HDL, hypertension, smoking, previous coronary artery disease, family history of arteriosclerosis (eg, myocardial infarction in males less than 50 years old, stroke).
Congestive heart failure symptoms: Orthopnea (number of pillows), paroxysmal nocturnal dyspnea, dyspnea on exertional, edema.
Peripheral vascular disease symptoms: Claudication, transient ischemic attack, cerebral vascular accident.
COPD exacerbation symptoms: Shortness of breath, fever, chills, wheezing, sputum production, hemoptysis (quantify), corticosteroid use, previous intubation.
Past medical history: Peptic ulcer disease, renal disease, diabetes, COPD. Functional status prior to hospitalization.
Medications: Dose and frequency. Use of nitroglycerine, beta-agonist, steroids.
Allergies: Penicillin, contrast dye, aspirin; describe the specific reaction (eg, anaphylaxis, wheezing, rash, hypotension).
Social history: Tobacco use, alcohol consumption, intravenous drug use.
Review of systems: Review symptoms related to each
organ system.
Critical Care Physical Examination
Vital signs:
Temperature, pulse, respiratory rate, BP (vital signs
should be given in ranges)
Input/Output: IV fluid volume/urine output.
Special parameters: Oxygen saturation, pulmonary
artery wedge pressure (PAWP), systemic vascular
resistance (SVR), ventilator settings, impedance
cardiography. General: Mental status, Glasgow coma score, degree of distress.
HEENT: PERRLA, EOMI, carotid pulse. Lungs: Inspection, percussion, auscultation for wheezes, crackles.
Cardiac: Lateral displacement of point of maximal impulse; irregular rate,, irregular rhythm (atrial fibrillation); S3 gallop (LV dilation), S4 (myocardial infarction), holosystolic apex murmur (mitral regurgitation). Cardiac murmurs: 1/6 = faint; 2/6 = clear; 3/6 - loud; 4/6 = palpable; 5/6 = heard with stethoscope off the chest; 6/6 = heard without stethoscope.
Abdomen: Bowel sounds normoactive, abdomen soft and nontender.
Extremities: Cyanosis, clubbing, edema, peripheral pulses 2+.
Skin: Capillary refill, skin turgor. Neuro
Deficits in strength, sensation.
Deep tendon reflexes: 0 = absent; 1 = diminished; 2 =
normal; 3 = brisk; 4 = hyperactive clonus. Motor Strength: 0 = no contractility; 1 = contractility but no joint motion; 2 = motion without gravity; 3 = motion against gravity; 4 = motion against some resistance; 5 = motion against full resistance (normal). Labs: CBC, INR/PTT; chem 7, chem 12, Mg, pH/pCO2/pO2. CXR, ECG, impedance cardiography, other diagnostic studies.
Impression/Problem list: Discuss diagnosis and plan for each problem by system.
Neurologic Problems: List and discuss neurologic problems
Pulmonary Problems: Ventilator management. Cardiac Problems: Arrhythmia, chest pain, angina. GI Problems: H2 blockers, nasogastric tubes, nutrition. Genitourinary Problems: Fluid status: IV fluids, electrolyte therapy.
Renal Problems: Check BUN, creatinine. Monitor fluids and electrolytes. Monitor inputs and outputs. Hematologic Problems: Blood or blood products, DVT prophylaxis, check hematocrit/hemoglobin. Infectious Disease: Plans for antibiotic therapy; antibiotic day number, culture results.
Endocrine/Nutrition: Serum glucose control, parenteral or enteral nutrition, diet.
Admission Check List
1. Call and request old chart, ECG, and x-rays.
2. Stat labs: CBC, chem 7, cardiac enzymes (myoglobin, troponin, CPK), INR, PTT, C&S, ABG, UA, cardiac enzymes (myoglobin, troponin, CPK).
3. Labs: Toxicology screens and drug levels.
4. Cultures: Blood culture x 2, urine and sputum culture (before initiating antibiotics), sputum Gram stain, urinalysis............
5. CXR, ECG, diagnostic studies.
6. Discuss case with resident, attending, and family.
Critical Care Progress Note
ICU Day Number:
Antibiotic Day Number:
Subjective: Patient is awake and alert. Note any events
that occurred overnight.
Objective: Temperature, maximum temperature, pulse,
respiratory rate, BP, 24- hr input and output, pulmonary
artery pressure, pulmonary capillary wedge pressure,
cardiac output.
Lungs: Clear bilaterally
Cardiac: Regular rate and rhythm, no murmur, no rubs.
Abdomen: Bowel sounds normoactive, soft-nontender.
Neuro: No local deficits in strength, sensation.
Extremities: No cyanosis, clubbing, edema, peripheral
pulses 2+.
Labs: CBC, ABG, chem 7.
ECG: Chest x-ray:
Impression and Plan: Give an overall impression, and
then discuss impression and plan by organ system:
Cardiovascular:
Pulmonary:
Neurological:
Gastrointestinal:
Renal:
Infectious:
Endocrine:
Nutrition:
Procedure Note
A procedure note should be written in the chart when a procedure is performed. Procedure notes are brief operative notes.
Procedure Note
Date and time:
Procedure:
Indications:
Patient Consent: Document that the indications,
risks and alternatives to the procedure were ex
plained to the patient. Note that the patient was
given the opportunity to ask questions and that the
patient consented to the procedure in writing.
Lab tests: Relevant labs, such as the INR and CBC
Anesthesia: Local with 2% lidocaine
Description of Procedure: Briefly describe the
procedure, including sterile prep, anesthesia
method, patient position, devices used, anatomic
location of procedure, and outcome.
Complications and Estimated Blood Loss (EBL): Disposition: Describe how the patient tolerated the
procedure. Specimens: Describe any specimens obtained and labs tests which were ordered. Name of Physician: Name of person performing procedure and supervising staff.
Discharge Note
The discharge note should be written in the patient’s chart prior to discharge.
Discharge Note
Date/time:
Diagnoses:
Treatment: Briefly describe treatment provided
during hospitalization, including surgical procedures
and antibiotic therapy.
Studies Performed: Electrocardiograms, CT scans,
CXR.
Discharge Medications: Follow-up Arrangements:
Fluids and Electrolytes
Maintenance Fluids Guidelines:
70 kg Adult: D5 1/4 NS with KCI 20 mEq/Liter at 125 mL/hr.
Specific Replacement Fluids for Specific Losses: Gastric (nasogastric tube, emesis): D5 1/2 NS with KCL 20 mEq/L.
Diarrhea: D5LR with KCI 15 mEq/liter. Provide 1 liter of replacement for each 1 kg or 2.2 lb of body weight lost.
Bile: D5LR with sodium bicarbonate 25 mEq/liter (1/2 amp).
Pancreatic: D5LR with sodium bicarbonate 50 mEq/liter (1 amp).
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